Treatment Interventions and Outcome

Mary completed 14 cognitive-behavioral therapy sessions. In the first treatment session, the clinician provided feedback in a collaborative manner regarding the assessment and diagnostic findings. Mary agreed with the conceptualization, and she and her clinician discussed her goals for therapy. Mary reported that her main objective was to be less depressed. The clinician suggested that therapy begin with an increase in Mary's social involvements and pleasurable activities. A schedule of pleasurable activities was generated, which included walking her dog, going to the store, and making phone calls to friends. Mary was reluctant, because socialization triggered PTSD symptoms, but she was hopeful about the potential benefits. Her homework was to keep a daily record of her activities and to monitor her mood and anxiety three times per day.

By the third session, it became clear that the treatment of Mary's depression was affected by her PTSD symptoms. She had attempted to go to public places, which led to initial feelings of being overwhelmed and subsequent feelings of despair. Mary also expressed her concerns about the helpfulness of therapy. The therapist made the decision that behavioral activation interventions were negatively impacted by intrusive thoughts and avoidance related to PTSD; thus, treatment needed to shift to PTSD.

The subsequent sessions of Mary's treatment involved a protocol of PTSD treatment, adapted from Ehlers and Clark (2000). Initial sessions included psychoeducation regarding the nature of PTSD and its treatment. A strong rationale was provided for the treatment of PTSD and the key element of thinking about the trauma more and discussing it in detail. In addition, thoughts of the trauma were triggered by current events, because the details of the event have become associated in Mary's mind with terror. Thus, neutral stimuli, such as public places, banks, and other people, triggered her anxiety. An important component of treatment included exposure to both the memory of events and current triggers.

Some sessions were devoted to relaxation and breathing exercises to reduce her state of arousal, and she reported benefits. Two sessions focused on reliving the experience of the traumatic event by recalling the details of it. Mary was reluctant to recall the details of the robbery; however, the solid rationale for treatment increased her willingness. As recommended by Ehlers and Clark (2000), she was instructed to recall the event in her mind's eye, making the image as realistic as possible, and included her thoughts and feelings about what was happening. She was asked to recall the event in the present tense. The therapist asked probing questions to help Mary stay with the memory. Cognitive restructuring was used to identify and discuss problematic thoughts and beliefs regarding the trauma.

The remaining sessions focused on in vivo exposure to the real-life triggers of Mary's anxiety. A hierarchical list of triggers was generated in session that included loud voices, customer service lines, and interpersonal situations in which tension may occur. Each week Mary chose an exposure situation of moderate difficulty to try on her own. Instructions were provided about the length of time she should spend in the situation, as well as coping strategies (e.g., breathing exercises, positive coping statements) for dealing with her anxiety. A record form was developed to assist Mary with this task. For example, Mary's first exercise was to return an item she had purchased from a store. Because she tended to avoid listening to strangers out of fear they would say something harmful to her, Mary was instructed to pay attention to the voices she heard while standing in line. Each week exposure was reviewed and any troubleshooting addressed. Mary began entering situations that she had previously avoided, including volunteering at a market, which resulted in a significant improvement in her depression.

The next stage of therapy was intended to address Mary's dysfunctional core beliefs, but treatment was terminated prematurely, because the robber's prison sentence ended and he was released. Mary and her common-law partner moved to another city due to her fear of encountering the perpetrator. At discharge, Mary's anxiety and depressive symptoms had improved with the treatment focused on her PTSD. At discharge, her BDI-II score was 23, suggesting that Mary was experiencing moderate depression. Her score on the PCL was 45, suggesting that she continued to experience some symptoms of PTSD but she did meet the criteria for the disorder.

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